2691 Liberty Church Rd 5 DAVIE COUNTY HEALTH DEPARTMENT )'A CAvAl =o��
. y•_ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name �.: .✓ , r=-,.. Date r .��, � a r:.+�4
Location ,, �,, ,� at r ,, ., _ /. f.✓:
Subdivision Name Lot No. Sec. or Block No.
Lot Size %- >" House '� Mobile Home _ Business _— Speculation
No. Bedrooms %' No. Baths No. in Family ^
Garbage Disposal YES p NO 0_'. Specifications for System:
Auto Dish Washer YES NO p s _
Auto Wash Machine YES in NO Fj , `•�,
Type Water Supply
*This permit Void if sewage system .described below is not installed within 36 months from date of issue.
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1
Improvements permit by
'Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
t
Certificate of Completions✓<--- -- Date-3' 1q - S� "
*The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
r
DAVIE COUNTY HEALTH DEPARTMENT
i
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS
A7) PS
U U
2) Soil Texture (12-36 in.) Sandy, S S S S '
Loamy, Clayey, (note 2:1 Clay) PS PS PS PS
U
3) Soil Structure (12-36 in.) S S S $
Clayey Soils PS PS PS PS
U
4) Soil Depth (inches) S S S S
PS PS PS
CIE,> U
5) Soil Drainage: Internal S S S S
PS
U U
External S S S S
PS PS PS PS
U U U U
6) Restrictive. Horizons
7) Available Space S. PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by �/ Title �✓ Date
SITE DIAGRAM
P f
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone a ' IC
1. Permit Requested By / '" '"��fy b , =S!eer e Business Phone
2. Address Aa* ,8�x3�/ cfCsv�%la /VE 7yd 8
3. Property Owner if Different than Above
Address
4. Permit To: a) Install_kL__Alter Repair
b) Privy Conventional ✓Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: Housed/Mobile Home Business
IndustryOther
b) Number of people , :C
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms_ Bath Rooms_ Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
t 7. Number and type of water-using fixtures:
commodes urinals garbage disposal
lavatory a showers a washing machine /
dishwasher sinks
8. a) Type water supply: Public Private_ Community
b) Has the water supply system been approved? Yes-No
9. a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor
10.'Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
S:T.
H��a f bay✓� R�� F LA-65
DCHD(6-82)
�tti�ie fdnixrt#g �PttY#I� �P�ttx#mei#
P.`O. BOX 665
'�ilncksinlle, �artll ;(�ttrulintt z7IIz8
OFFICE OF THE DIRECTOR TELEPHONE
. - 17041 694-5885
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May 23, 1983
Mr. Lee Shore
Route #6,. Box 321-A
Mocksville, North Carolina
Mr. Shore:
This letter is regarding a soil/site evaluation done
by this office on a 20 acre tract of land you own on Liberty
Church Road in Davie County.
The estimated percolation rate for the soil evaluated
would be 120-240 minutes per inch, however, based on design
modification and linear footage this office feels the
system that has been designed if installed properly and with
proper maintenance should function properly for an indefinite
period of .time. It should be noted that there is ample
repair room should the system fail.
If you have any questions, feel free to call this
office.
Sincerely,
A0 I�- 6WXA` 7
Robert B. Hall, Jr. R.S.
jh Sanitarian